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COUNTY Dutehess
g:~~~~TWN Wappinger
~~~I~~~R1368
NUMBER 33
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
1. A FULL NAME
Alexander J. B~I kaF3wdSURNAME
11. A. FULL NAME
FIRST Aptil S. ~URRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~\iM~~~~t':e~~sBuI bot
D. SOCIAL SECURiTY NUMBER 076-64-1417
12. RESIDENCEA.N Y,TATE) 8. D~
C. CHECK ONE 0 CITY n. TOWN 0 VILLAGE
AND ".
SPECIFY Vv'aoch 10m
D. STREET ADDRE~S11 Ail /Ju ~s Hili Road
E. is RESIDENCE WITHIN LIMITS OF C~OR INCORPORATED VILLAGE?
13. A. AGE23 13.B. DATE OF BIRTH
14. EMPLOYMENT
FIRST
"-
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 111-66-2015
2. RESIDENCE A N YTATE) B. Dt1IBtl~
C. CHECK ONE 0 CITY 1.1 TOWN 0 ViLLAGE
AND ,.,
SPECIFY 'vVappinger
D. STREET ADDRESS 11 All Angels 111115 Road
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 27
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Technical
B. TYPE OF INDUSTRY OR BUSINESS Pace University
5. PLACE OF BIRTH Roughl.....rHew York
6. FATHER
A. USUAL OCCUPATION A&:countit
I IY
B. TYPE OF INDUSTRY OR BUSINESS Roger & 80M Cone! ete
15. PLACE OF BIRTH RhluebedciiiTNewT'tork
16. FATHER
A. NAME Alexander Burica, Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. NAME Bruce Hf:ese
B. COUNTRY OF BIRT~ 8 A
17. MOTHER
A. MAIDEN NAME I<Im~ Cservak
B. COUNTRY OF BIRT~ S A -
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A. MAIDEN NAME Undll Lunn
B. COUNTRY OF BIRTH U 8 A
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
B. HOW DiD LAST MARRIAGE END?
o
(3) 0 DIVORCE
o
(2) 0 DEATH
o
(3) 0 DIVORCE
o
(2) 0 DEATH
o
B. HOW DID LAST MARRIAGE END?
(3) 0 ANNULMENT
/ /
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
a:
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o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
best of my knowledge and belief that the information I provided is true and
o 0
o 0
o 0
o 0
at no legal impediment exists
\.
21. SIGNATURE OF GROOM ~
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE
by New
or
omestic
~
{ SEAL }
"-v-I
NAME (PRINT)
SIGNATUR~
MAILING ADDRESS
DATE 04J07 /2003
YEAR
MONTH
YEAR
MONTH
TIME
ZIP
TA
YPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
1~
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~urC M
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ OF 0 TOWN OF 0 VILLAGE OF
[SPECIFY 'J:'o ""' U.lC.~ f.. t:JS tL
ST.
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
NAME (PRINT)
SIGNATURE ~
DOH.9B (1119B)
NAME (PRINT)
SiGNATURE ~ ·